GH symposium 2016_1

How Rwanda is Redefining HIV Care

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Neil Gupta, MD, MPH, during his graduation from BWH’s Division of Global Health Equity Doris and Howard Hiatt Global Health Residency Program. Photo by Justin Knight.

In recognition of Dec. 1 as World AIDS Day, BWH physician Neil Gupta, MD, MPH, contributed a compelling op-ed piece to The Atlantic on HIV treatment in Rwanda. Gupta, the deputy clinical director for Partners In Health in Rwanda, has witnessed the success of Rwanda’s approach to HIV care and treatment, and the impact it has had on the lives of Rwandans.

He writes: “In Rwanda, where just 20 years ago a genocide claimed approximately 1 million lives, the government has transformed HIV care for the poor by redefining the standards for successful treatment. More than three decades into the epidemic, many national and international agencies are still counting the basics—how many people get infected, how many people receive medication, how many patients die. Success in Rwanda, meanwhile, is measured not in the number remaining alive, but rather in how many are actually able to take their medications as directed and suppress the virus in their bodies to a level where it is essentially non-existent. In Rwanda, success is achieved when people living with HIV can earn a living, support their family, raise their children, and care for their community no differently than their peers.”

Read the complete op-ed here.

GH symposium 2016_1

The Coming Transformation in Global Health

The 20th century witnessed a monumental transformation in hospitals: once primarily places for poor people to die, hospitals became institutions that cured illness and promoted health. A range of facilities and professionals dedicated to treating the sick grew in tandem with the proliferation of hospitals, creating the health care systems we have today.  

Health care systems are now pervasive enough that even developing countries have structures for delivering care. Advances in treating HIV, heart disease, and other chronic conditions mean that a significant part of the population now lives for years in less-than-perfect health.  As we grow increasingly reliant on this care, the question before us is how to strengthen health systems in order to deliver quality care to all who need it.

This was the pivotal theme at the talk “The coming transformation in global health,” held at Harvard Medical School on Feb. 28.  Moderated by Paul Farmer, MD, PhD, chief of the Division of Global Health Equity, the discussion was framed by Lord Nigel Crisp KCB, former head of the National Health Service in the United Kingdom, and Dean Julio Frenk, MD, MPH, PhD, former minister of health of Mexico and current dean of the Harvard School of Public Health.

Frenk discussed the challenges and opportunities he encountered while reworking the health care system in Mexico. We can create a platform for enlightened social change by carefully and conscientiously restructuring our health care systems, but Frenk felt it was vital that these reforms be evidence-based and involve explicit ethical deliberation.  When these systems change for the better, they can have a tremendous impact: 30 percent of children with leukemia in Mexico had to stop treatment because their families ran out of money, but this number dropped to two percent after the implementation of health care reforms.

Having worked extensively in both the UK and developing nations, Crisp was particularly struck by the lack of health workers in many resource-poor settings. One way around the exodus of trained medical professionals from their countries of origin is to break down the demarcations between health professions. Crisp cites settings in Africa where nurses have been trained to do Cesarean sections—patient outcomes are comparable to doctors performing the operation, with the added bonus that nurses are less likely to move abroad.

Another potential solution for limited availability of medical professionals is to engage patients in their own care, as well as with helping and supporting fellow patients. Even in settings with abundant staff and resources, such as a self-dialysis clinic in Sweden, this approach can energize and engage patients, lower infection rates, and increase patient satisfaction. Crisp emphasized that health is a co-production function: it is not something doctors give patients, but something that patients create with intermittent assistance from clinicians.

Throughout the program, the speakers underscored that health is not separable from other human endeavors. Just as the duty of hospitals shifted from comforting the dying to curing, the challenge going forward is to reform health care systems to deliver care not just to the privileged, but to all in need.